HOUSE DOCKET, NO. 1734        FILED ON: 1/13/2009

HOUSE  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  No. 1079

The Commonwealth of Massachusetts

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In the Year Two Thousand Nine

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An Act to further define adverse determinations by insurers..

Be it enacted by the Senate and House of Representatives in General Court assembled, and by the authority of the same, as follows:
 

Section 1 of Chapter 176O of the General Laws is amended by adding the following new sentence after the word “effectiveness” in the definition of “Adverse determination”:

Provided however, that in making said adverse determination, the carrier or its designated utilization review organization shall defer to the judgment of the treating clinician unless there is a preponderance of evidence that the requested admission, continued stay or other health care service does not meet the requirements for coverage based on medical necessity, appropriateness of health care setting and level of care, or effectiveness.